The American Academy of Pediatrics recently rated biofeedback as evidence-based "Level 1-Best Support" for treating ADHD. We spoke to Anthony Silver, MS, MA, MFT, BCIA-EEG, director of Gray Matters in Westport, CT, about biofeedback, neurofeedback, and brain mapping and how they help diagnose and treat ADHD.
What are brain mapping and neurofeedback, and how do they help treat ADHD?
Biofeedback is essentially showing a person what their body is doing in some way, letting them know so they can learn control it. Biofeedback includes things like heart rate variability training where you become aware of what your heart is doing and skin conductivity so you can reduce your anxiety and anxiety responses. Neruofeedback is a form of biofeedback, and it’s showing a person what their brain is doing, so it’s biofeedback that uses EEGs—brainwaves.
What we do is measure the electrical activity on the cortex by placing electrodes on the scalp, which is the same thing neurologists do and has been done to measure cortical activity—brain activity—for decades. But the difference is that we don’t just use it diagnostically, although we do, do that, we also use it as a training tool. For example, if you have a neurological condition where you have ADHD, you should have frontal slowing—the frontal lobes of your brain are normally working too slowly. So we attach electrodes to the front part of the head, and we reward children for speeding up their brains, essentially focusing, concentrating, so that they learn how to do it.
A lot of the conditions that we associate with functional difficulties—ADHD, anxiety—they’re all reflected by measurable brain states that are different. And so what we do with neurofeedback—or EEG biofeedback as it’s called sometimes—is we train the brain itself to work differently, which is a more permanent treatment. But you’re also dealing with the actual causes of the behaviors or the symptoms and not just the behaviors or symptoms. When you treat a child with ADHD for example, you’re using an external influence. You’re using medication introduced from the outside to change the chemical state of the brain on a temporary basis. What we do is we work on the brain itself and teach it to change its own self and hopefully reduce or eliminate the need for medication.
Comprehensive brain mapping, or QEEGs, which are incredibly valuable for diagnostic work, map the functioning of the brain and identify what areas of the brain are not working as or as well as they should. Those findings match the symptoms on a very, very consistent basis. We use that as a road map for treatment and we can also evaluate how effective our treatment has been, not just from the improvement in the child’s attention or reduction of their symptoms, but also in the changes of the mapping itself. That is a huge advance because normally when you’re evaluating children, you’re using subjective evaluations. You’re using rating scales. You’re using people’s opinion. We can measure what the brain is doing itself in a very objective, very repeatable, very valid and reliable way. We can monitor the progress in the same way. So we have really quite scientific yardsticks that we can measure ourselves by as well, and measure the effectiveness of what we are doing in treatment.
Is brain mapping done to aide with diagnosis or are all children who come to you already diagnosed with ADHD?
Many come in with a diagnosis and many are wrong—lot of issues look like ADHD, but are not ADHD. And giving these kids medication is often incorrect. It’s often done on an experimental basis—as part of the diagnostic process, rather than a product of it. Often times, a parent will take their child to the family doctor who will say, “We’ll try Adderall, or we’ll try Vyvanse, or we’ll try one of these other stimulants and we’ll see if it helps. If it helps, then your child has ADHD.” But the reality is stimulants help most people focus in the classroom, and the problem is that these children have significant side effects. A lot of them become more anxious, some of them become socially withdrawn, some have sleep issues, and some have huge appetite issues.
But in terms of diagnosis, because a lot of different issues look like ADHD, even when you test the child, you don’t know why they’re not concentrating. It could be that they’re anxious for a variety of reasons, and their attention won't be as good as it would be otherwise. What we can see with a brain map is whether they are anxious or whether they really do have the frontal slowing that characterizes proper ADHD. And even more interesting, we can predict because of that how a child will respond to medication based on the brain map. And that’s huge. We can say really pretty confidently, “If you give this child a stimulant, it will help.” Or “Do not give this child a stimulant. They’re really anxious, you run the risk of making that anxiety much worse. Don’t under any circumstances do it.”
It’s amazing technology and it’s improving significantly each year. It has a tremendous amount to offer, not as an alternative to what’s out there right now, and this is really important as well, but in addition to it. If you do a really good neuropsychological or psychological assessment and you do a brain map with it, the two should confirm each other, and then you have confidence that what you’re really recommending is good and accurate and can really help the child, even if you don’t do neurofeedback, the brain mapping side of it is unbelievably important.
Is there a benefit to having brain mapping and biofeedback done earlier in life or is it effective at any age?
It’s effective at any age because what your doing with the brain map is you’re measuring the brain activity and then you’re comparing it with a person of the same sex and same handedness and the same age. So you can map a brain of a 3- or 4-year-old or a 75-year-old. The important thing is you’re seeing how that brain differs from what you would expect using a massive database of people who are comparable—same age, same sex—and non-symptomatic. The important thing is getting the diagnosis right. That is the key. And you can save a lot of time and a lot of heartache by getting it right. You can save these kids from being on meds that sometimes are not right. And you can avoid using medication as part of the diagnostic process instead of as a result of a conclusion.
Anthony Silver, MA, MS, MFT, BCIA-EEG, is the director of Gray Matters in Westport, CT. As a board-certified neurofeedback clinician, Silver has treated hundreds of children and adults with neurofeedback. Silver is also on staff at the Southfield Center for Development in Darien, CT, where he works as a psychotherapist, working with children, adolescents, and adults.
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